CESAREAN SCAR PREGNANCY - A RARE ENTITY: TWO CASE … · Cesarean scar pregnancy is the implantaon of an embryo within the mymometrium of prior cesarean scar which is a rare variant
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Mahato K et al
CESAREAN SCAR PREGNANCY - A RARE ENTITY: TWO CASE REPORTS
Affiliation
1. Resident, Department of Gynaecology and Obstetrics, Affiliated
Hospital of Inner Mongolia University for the Nationalities,
Tongliao, PR China.
2. Professor, Department of Gynaecology and Obstetrics, Affiliated
Hospital of Inner Mongolia University for the Nationalities,
hysteroscopic evacua�on has been suggested achieving 3,4sa�sfactory results. However, no universal treatment
guidelines have been established �ll date and actual
experience with CSP con�nues to be based on individual
case reports, small series. We present two cases of CSP with
different management strategies opted at our ins�tu�on.
In this ar�cle we discuss the clinical features, diagnosis and
various modes of treatment along with review of literature.
CASE 1
A 37 year old G6P2A3 presented with vaginal bleeding and
six weeks of amenorrhea. She had two cesarean deliveries
and three induced abor�ons in between the deliveries.
There was lower abdominal tenderness on deep palpa�on
and the ultrasonography showed a gesta�onal sac
containing yolk sac of 2.1 × 1.1 cm located in the anterior
lower uterine wall in the area adjacent to her prior cesarean
scar (Figure 1). Serum ß-hCG at the presenta�on was
28501mIU/mL. So with the diagnosis of CSP, the pa�ent was
planned for local methotrexate injec�on into the chorionic
sac under transabdominal ultrasound guidance using a 22-
gauge needle, the amount of MTX being 50mg/m², without
anesthesia. Following the procedure, the level of ß-hCG
showed an ini�al increment to 29885 mIU/mL followed by
gradual decreasing pa�ern. However even a�er a week
there was persistent mild vaginal bleeding with residual
mass evident in USG; although there was a drop in ß-hCG to
4533mIU/mL. Hence, ultrasound guided suc�on and
evacua�on of sac was done under IV anesthesia (Figure 2).
There was no complica�on and the symptoms along with
the ß-hCG level subsided gradually. She was discharged and
followed up a�er three weeks with pelvic sonogram
showing complete resolu�on of mass and ß-hCG level being
declined to negligible level.
CASE 2
A 29-year-old, G2P1 a�ended the emergency with acute lower abdominal pain, vaginal bleeding and amenorrhea of twelve weeks. She had a cesarean delivery nine months ago. On further inves�ga�on the serum ß-hCG was 20596 mIU/mL and transvaginal sonography revealed bulged anterior myometrium with a gesta�onal sac of 4.9 × 3.0 cm diameter containing non viable fetus with a crown-rump length of 1.2cm at anterior wall of the uterine isthmus around previous cesarean scar. A mixed hypoechoic lesion of 3.7 × 2.9cm was also present around the implanta�on site surrounded by vascular flow as demonstrated by color Doppler (Figure 3). Due to significant ongoing bleeding we planned for transvaginal hysterotomy and excision of ectopic mass under GA. The pa�ent was placed in lithotomy posi�on with the vaginal retractors inserted into the anterior and posterior vaginal wall, sufficient enough to expose the cervix. With the Allis forceps placed on the anterior cervix, a con�nuous trac�on was applied to pull the cervix down to the vagina to completely visualize the cervix. A transverse incision was made at the anterior cervicovaginal junc�on and the bladder was dissected away un�l the anterior peritoneal reflec�on was iden�fied. A�er retrac�ng
Figure 1. Transvaginalultrasonogram showing 2.1 × 1.1 cm gesta�onal sac implanted in the anterior lower segment of the uterus.
Birat Journal of Health Sciences Vol.2/No.3/Issue 4/ Sep-Dec 2017
313
Case Report Mahato K et al
the bladder upward, the implanta�on of the ectopic mass in the isthmic por�on of uterus was iden�fied. A transverse incision was made over the most prominent area of the mass containing the gesta�onal sac. The ectopic �ssue was then removed and cure�age through the incision. A�er complete removal of the scar �ssue the uterine wall defect was closed with absorbable sutures. There was minimal vaginal bleed at the end of procedure. Postopera�vely there was gradual decline in ß-hCG with disappearance of the mass. She followed a�er three weeks with negligible ß -hCG.
DISCUSSION
CSP is a rare condi�on where the implanta�on of conceptus takes place within the uterine scar of a previous CS. The gesta�on of CSP is located within the area surrounded by myometrium and fibromuscular �ssue of the scar.³ Its incidence is rapidly increasing due to increase in number of CS and improved diagnos�c methods. Timely diagnosis and appropriate management is essen�al because if le� untreated, it may lead to serious complica�ons such as uterine rupture, hemorrhage, hypovolemic shock, disseminated intravascular coagula�on, and even maternal death. This abnormal form of implanta�on occurs through microtubular tract created between the previous CS scar and the endometrium canal, following into the myometrium. The tract is formed due to uterine manipula�on such as
5cure�age, cesarean sec�ons. It is not certain whether the risk of CSP is related to the number of previous CS, however there are evidence correla�ng the indica�on of CS and occurrence of CSP. Maymon et al. reported an interes�ng associa�on between cesarean deliveries for breech and
6subsequent scar pregnancies. The underdevelopment of lower uterine segment in the condi�ons like breech cesarean delivery, preterm cesarean delivery or following failure of labor progression predisposes to CSP. Another factor for abnormal implanta�ons may be the change in surgical technique from double to single layer closure in uterine repair however no such evidence is reported in
3literature. The dura�on between CS and occurrence of CSP is not clearly understood as some CSP occur within months
1whereas some reported many years apart. Transvaginal sonography and Doppler USG imaging are the diagnos�c tool to facilitate early detec�on of CSP. Apart from prior CS, amenorrhoea and a higher than normal ß-hCG level, there are various transvaginal sonography criteria for the diagnosis. The sonographic criteria are: no gesta�onal sac in the uterine cavity; empty cervical canal; gesta�onal sac located in the long narrow sec�on of the anterior uterine wall; unhealthy myometrium between bladder and the
7 gesta�onal sac. CSP is confused with cervical pregnancy, spontaneous abor�on in progress, and a low implanted intrauterine pregnancy hence the sonographic criteria
2should be followed to confirm the diagnosis. Most cases of CSP are generally diagnosed in the first trimester and termina�on of pregnancy is recommended once diagnosis is confirmed. Risk involving if allowed to progress to term results in massive bleeding and uterine rupture leading to hysterectomy and other serious catastrophic complica�ons. Because of uncommon occurrence of such implanta�on, no universal treatment protocol is established. The management is rela�vely controversial and current standards of therapy have been derived from limited cases.
There are different treatment methods of CSP ranging from medical to surgical or some�mes, a combina�on of these. The medical managements are systemic or local methotrexate or combined, local embryocides (local potassium chloride or hyperosmolar glucose) whereas the surgical modali�es being laparotomy /laparoscopic evacua�on; hysteroscopic evacua�on; dila�on and cure�age; vaginal hysterotomy
Figure 3. Color Doppler transvaginal USG showing a gesta�on sac 4.9 × 3.0 cm with a mixed echoic mass of diameter 3.7 × 2.9 cm in the lower segment cesarean scar
Figure 4. Histology showing inters��al trophoblas�c cell hyperplasis within the fibro muscular �ssue of scar.
3,4and repair; selec�ve UAE; sac aspira�on. The treatment method is selected on the basis of clinical presenta�on and trea�ng clinician's skill and experience. We had excellent results in both cases. There is no agreement on the best treatment methods of CSP in the published literatures and the decision of treatment modali�es have been made mostly by the individual physicians according to their skill and experience. Every literature has emphasized their own modali�es of treatment with best results. Peng et al. .
performed a clinical study on 104 CSP pa�ents and summarized that local MTX injec�on is more effec�ve over systemic in terms of remission of serum B-hCG and uterine
8mass disappearance whereas Timor-Tritsch et al. had excellent results with combined intramuscular and local
9MTX injec�on in 26 pa�ents. Wang et al. treated 71 pa�ents with Methotrexate therapy (local or IM) with or without suc�on cure�age and concluded that both could treat majority of CSP successfully, but the combina�on has
10be�er outcome. Seow et al. also had be�er results with local methotrexate over surgical or invasive techniques, including dilata�on and cure�age which accounted for high
1morbidity and poor prognosis. There has been some reports with local injec�on of KCL. Salomon et al. reported the first case of heterotopic pregnancy which was
11successfully treated with USG guided KCL injec�on. Our second case was treated with transvaginal hysterotomy which is a less invasive approach with a short opera�ve �me, minimum blood loss and reducing the overall hospital
Case Report Mahato K et al
stay. Kang et al. and He et al. successfully treated pa�ents 12.13with this approach and achieved excellent results.
Hysteroscopic or laparoscopic removal replacing laparotomy has also been described in literature for CSP. Yang et al evaluated 39 CSP and concluded that hysteroscopic
14removal was feasible and safe procedure. Similar results with hysteroscopy and laparoscopy has been a�ained by
15 Wang et al. UAE followed by hysteroscopy or suc�on cure�age has also been proven to be effec�ve treatment. Li et al. evaluated 124 CSP and treated with three different modali�es and concluded that UAE with hysteroscopy to be
16the most efficient.
CONCLUSION
CSP life threatening condi�on so early diagnosis and making reasonable choice of treatment seems cri�cal to conserve the women's reproduc�ve future. From the ar�cles reviewed we come to a conclusion that among the several treatment modali�es available, the combina�ons of different techniques is useful than any method used alone. This review is to create an awareness of the poten�ally risky clinical condi�on, as cure�age is rou�nely performed due to increase rate of induced abor�ons which predispose to this condi�on. Whatsoever treatment op�on we opt for, our primary goal is to reduced the associated morbidity and mortality associated with this condi�on and to retain pa�ent's future fer�lity.
1. SeowKM , Huang LW, Lin YH , Lin MYS, Tsai YL , Hwang JL. Cesarean
scar pregnancy: issues in management. Ultrasound Obstet
Gynecol. 2004; 23: 247–253.
2. JurkovicD, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ.
First-trimester diagnosis and management of pregnancies
implanted into the lower uterine segment Cesarean sec�on sca.
Ultrasound Obstet Gynecol. 2003; 21: 220–227.
3. Rotas AM, Haberman S, Levgur M. Cesarean Scar Ectopic
PregnanciesE�ology, Diagnosis, and Management.ObstetGynecol
2006; 107:1373–81.
4. Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic
pregnancy: diagnos�c challenges and management op�ons. The
Obstetrician &Gynaecologist. 2017;19:13–20.
5. Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG. 2007
Nov; 114: 253-263
6. Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A.
Ectopic pregnancies in a Caesarean scar: review of the medical
approach to an iatrogenic complica�on. Human Reproduc�on
Update. 2004;10(6): 515–523
7. Vial Y, Pe�gnat P, Hohlfeld P. Pregnancy in a cesarean scar.
Ultrasound Obstet Gynecol. 2000; 16:592–3.
8. Peng P, gui T, Liu XY, Chen W, liu Z.Compara�ve effcacy and safety of
local and systemic methotrexate injec�on in cesarean scar pregnancy.
Therapeu�cs and Clinical Risk Management. 2015;11: 137–142.
9. Timor-Tritsch IE, Monteagudo A, Santos R. The diagnosis,
treatment, and follow-up of cesarean scar pregnancy. Am J Obstet
Gynecol. 2012; 207:44.e1-13.
10. Wang JH, Xu KH, Lin J , Xu JY, Wu RJ, Methotrexate therapy for
cesarean sec�on scar pregnancy with and without suc�on
cure�age. Fer�lity and Sterility 2009 Oct ; 92( 4)1208-13
11. Salomon LJ,Fernandez H, Chauveaud A, Doumerc S, Frydman R.
Successfulmanagement of a heterotopic Caesarean scar
pregnancy: potassium chloride injec�on with preserva�on
of the intrauterine gesta�on: Case report. Human Reproduc�on
2003; 18(1) :189–191.
12. Kang SY, M.D, Park BJ, Kim YW, Ro DY. Surgical management of
cesarean scar ectopic pregnancy: hysterotomy by transvaginal
approach. Fer�lity and Sterility.2011 July; 96(1):25-28.
13. He M, Chen MH, Xie HZ, Yao SZ, Zhu B, Feng LP, Wu YP. Transvaginal
removal of ectopic pregnancy �ssue and repair of uterine defect for